DTIN0210

Case report DeNtaltribuNe|april-June, 201024 Introduction Pregnancy is a delicate condi- tion, involving complex physi- cal and physiological changes.1 Modification of metabolism, immunology, and high level of hormones make it possible for fetus to grow & develop, ending up with labor. Variations of these hormones cause some changes on skin and oral mucosa.2 The changes progress due to increased level of sex hormones in blood and saliva. These hor- mones are thought to be the reasons for occurrence of infla- mmatory process and the epulis gravidarum.3 The progesterone & estrogen receptors are situated in basal and spinous stratum of the ep- ithelium, and in the connective tissue. That is why those cells are influenced by a high level of pregnancy hormones.4 Proges- terone dilates blood vessels, makes them more permeable, and increases proliferation of capillary vessels. Estrogen reg- ulates the proliferation, differ- entiation, and keratinization of the gingival tissue. These hor- mones increase gingival bleed- ing, cause gingival growth, and lead to deepening of periodontal pockets as well.5 Epulis gravidarum is a quite rare gingival disorder occurring in 1.8 to 5% of pregnant women, and it affects more commonly the anterior region of the upper jaw.6 It is a smooth or lobulated exophytic lesion and manifests as a pink, red, or purple erythe- matous papule with peduncu- lated or sessile base.1 It usually arises in the 2nd trimester, grows gradually over a few months time, and it also tends to bleed. After delivery of the child, it may regress and disappear entirely.7 The purpose of this article is to describe a gingival swelling in a five months pregnant 26- year-old woman, which grew very rapidly unlike for this kind of tumor mimicking a malignant neoplasm. The lesion was not painful and grew very rapidly over a three week period. The histo- pathological examination reve- aled granulation tissue with non-neoplastic proliferation of endothelial cells, suggestive of epulis gravidarum. Case Description A 26-year-old female was refer- redwiththechiefcomplaintofan extensive gingival enlargement on the lower right anterior tooth region.Thelesionwasofnegligi- ble size when the patient first noticed it three weeks ago, but had grown rapidly over the past twenty days to attain the present size. The patient’s medical history revealed that she was at five months of gestation with no systemic disease. Clinical examination reve- aled an isolated exophytic, pedunclated lesion on the man- dibular right buccal side bet- ween the interdental gingival of lateral incisor and canine. It measured approximately 2.5 cm in diameter with some areas of erythema. The lesion was rough and firm in consistency on palpation that bled minimally (Fig. 1). The swelling also inter- fered with eating and speech. On examination, patient’s oral hygiene was found good. Excisional biopsy of the swelling with a wide margin was performed (Figs. 2 & 3). The histopathological examination revealed young granulation tissue with non-neoplastic pro- liferation of endothelial cells and the enlargement of blood capillaries. Infiltration of acute and chronic inflammatory cells in a collagenous matrix was also present. Surface of the lesion showed hyperplastic parakera- tinised stratified squamous epi- thelium with areas of atrophy and ulcer. These findings were consistent with a histopatho- logical diagnosis of epulis gravidarum. After three weeks of post- operative followup, clinical appearance of normal gingiva was present at the site of the lesion (Fig. 4). Discussion Epulis gravidarum is also known as “Pyogenic granuloma”. The term is somewhat a misnomer in that the lesion is not pus producingas“pyogenic”implies. It is however, a tumor of gra- nulation tissue, as granuloma implies.1 It has been called an epulis, because it is located more frequently in the gingiva. Some other terms used are “granuloma telangiectaticum” and “pregnancy tumor”. The term “hemangiomatous granu- loma” was suggested by An- gelopoulos to accurately reflect the characteristic histopatho- logic picture (hemangioma-like) and the inflammatory nature (granuloma) of the lesion.8 Clinically it presents as a lesion that is pedunculated or broad based, highly vascular- ized, smooth, edematous, hem- orrhagic, soft, red with glossy surface and hardened when it had been longstanding. It could be a single or multiple well localized outgrowth, painless or with dull pain. It usually is not bigger than 2 cm in the diameter.9 Differential diagnosis inclu- des peripheral giant cell granu- loma, epulis, peripheral ossify- ing fibroma, metastatic cancer, hemangioma, conventional gra- nulation tissue, hyperplastic gingival inflammation, angio- sarcoma, kaposi’s sarcoma and non-hodgkins lymphoma.10 Conclusion Epulis gravidarum represents an important differential diag- nosis of oral masses and can behave in a very aggressive fashion, mimicking a malignant tumor. Excised specimens should be sent for histopatho- logical reports to exclude malig- nancy. It is acceptable practice to excise aggressive variants of this lesion during pregnancy to avoid distressing side effects. References 1. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J Oral Sci. 2006; 48: 167-75. 2. Erickson CV, Matus NR. Skin disorders of pregnancy. Am Fam Physic. 1994; 3: 602-10. 3. Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002; 60: 257-64. 4. Zeeman GG, Veth O, Dennison D. Focus on primary care on periodontal disease. Implica- tions on women’s care. Obst Gynecol Survey. 2001; 56: 43-9. 5. Henry F, et al. Blood vessel changes during pregnancy: a review. Am J Clin Dermatol. 2006; 7: 65-9. 6. Paradowska A, Slawecki K, Chojak EG. Pregnancy tumor: review of literature. Dent Med Probl. 2008; 45(1): 51-4. 7. Ababneh K, Khateeb T. Aggres- sive pregnancy tumor mimic- king a malignant neoplasm: a case report. J Contemp Dent Pract. 2009 Nov 1; 10(6): E072-8. 8. Angelopoulos AP. Pyogenic granuloma of the oral cavity: Statistical analysis and its clini- cal feature. J Oral Surg. 1971; 29, 84-9. 9. Daley TD, Nartey NO, Wysocki GP. Pregnancy tumor: an ana- lysis. Oral Surg Oral Med Oral Pathol. 1991; 72(2): 196-99. 10. Czerninski R et al. Comparison of clinical and histological diag- nosis in lesions of oral mucosa. Oral Surg Oral Med Oral Pathol Oral Radiol Endond. 2007; 103 (4): e20. DT Fig. 1: Pre-operative view Fig. 2: Excised lesion Fig. 3: Sutured with 6-0 silk sutures Fig. 4: Post-operative view Epulis gravidarum mimicking a neoplasm A case report by Dr Deepak Chopra, Dr Mayur Kaushik, Dr Deepak Kochar, and Dr Sidharath Malik, India Dr Deepak Chopra is a reader in the department of periodontology at Inderprastha Dental College at Ghaziabad, India. He can be contacted at deepakchopra2010 @gmail.com. Dr Mayur Kaushik is a reader in the department of periodontology at Subharati Dental College at Meerut, India. Dr Deepak Kochar is an assistant professor in the department of periodontology at Inderprastha Dental College at Ghaziabad, India. Dr Sidharath Malik is an assistant professor in the department of periodontology at Inderprastha Dental College at Ghaziabad, India. About the authors